ULTRA FAST-FIX™ Meniscal Repair System - Smith & Nephew

Knee Series
Technique Guide
ULTRA FAST-FIX
Meniscal Repair System
All-Inside Meniscal Repair
with the ULTRA FAST-FIX
Meniscal Repair System
Nick Sgaglione, MD
David Caborn, MD

Reviewed by:
Nick Sgaglione, MD
Associate Professor of Orthopedic Surgery
Albert Einstein College of Medicine
Great Neck, NY
David Caborn, MD
Director of Sports Medicine
University of Louisville
Louisville, KY
2

All-Inside Meniscal Repair
with the ULTRA FAST-FIX
Meniscal Repair System
Introduction
Repair of peripheral and red/white meniscal tears
has become the standard of care as evidence
accumulates supporting meniscal preservation and
its role in joint nutrition, lubrication, stability, load
transmission, shock absorption, neuromuscular
proprioception, and prevention of intra-articular
chondrosis and arthrosis.
Inside-Out and Outside-In procedures require
additional incisions and dissection to avoid
neurovascular complications and have the potential
to cause capsular tethering, neuroma formation,
and suboptimal repair tension secondary to knot
tying over excess tissue. In addition, prolonged
intraoperative and tourniquet time can cause
increased pain and morbidity as well as increased
anesthesia costs.
The All-Inside arthroscopic approach has gained
popularity because of its insertion ease and
potential minimization of the aforementioned
problems. However, many of the devices used
in this approach have demonstrated inferior
biomechanical properties and have been associated
with breakage, loosening, distraction of the repair,
neurological injury, subcutaneous prominence, and
articular cartilage abrasion and damage. These
complications have contributed to a recent trend
back to the Inside-Out and Outside-In techniques,
despite their inherent difficulties.
3

Overview
The ULTRA FAST-FIX Meniscal Repair System (Photo 1) provides a strong, reproducible, reliable, and time-efficient meniscal
repair with equal biomechanical properties to the open vertical mattress suture technique 1 . This result is achieved without the
associated comorbidities of Inside-Out or Outside-In meniscal repair and without the need for intra-articular knot tying.
The ULTRA FAST-FIX Meniscal Repair System also gives the surgeon the versatility of placing horizontal or vertical mattress
suture fixation, without risk to neurovascular structures. As with all arthroscopic procedures, good visualization of the
meniscal tear and adequate arthroscopic distention are essential. To minimize the potential for damage to neurovascular
structures, Smith & Nephew recommends the use of the curved delivery needle and the variable depth penetration limiter (as
indicated by the meniscal tear position, especially if a vertical mattress suture is utilized).
Diamond rasp, 45°
Diamond rasp, 90°
Curved knot pusher/suture cutter
Straight knot pusher/suture cutter
ULTRA FAST-FIX, Reverse Curved
ULTRA FAST-FIX, Curved
Blue split cannula
ULTRA FAST-FIX AB, Curved
Suture funnel
Metal slotted cannula
Adjustable depth penetration limiter
Depth probe
Photo 1. ULTRA FAST-FIX Meniscal Repair System
4

Setup
Each ULTRA FAST-FIX device contains two 5 mm
polymer integrated anchors (resorbable or bio-inert),
with a pre-tied, self-sliding knot comprised of #0,
non-absorbable, UHMW polyethelene ULTRABRAID
co-braid suture. The entire system is packaged in
an easy-to-insert, integrated delivery needle. The
anchors are placed into the meniscus sequentially,
seated safely beyond the capsule, and are then
tightened in a simple manner without the need for
arthroscopic knot tying (Photos 2 and 3).
The dark blue sheath comes preset to a depth of 25
mm from the tip of the needle and 17 mm from the
back of the implant, which has been shown to avoid
neurovascular injury while allowing predictable
meniscocapsular placement 2 .
Peripheral, popliteal, hiatal, and mid-1/3 medial
meniscus tears may require penetration less than
the 17 mm allowed by the dark blue sheath. Use of
the meniscal depth probe, in conjunction with the
trimmable depth penetration limiter (white plastic
sheath), allows controlled penetration (Figures 1a
and 1b).
If the trimmable depth penetration limiter is used
with the split cannula, then the split cannula should
be completely split before inserting it over the
white depth penetration limiter, to allow for easier
removal.
Photo 2. Completed repair - horizontal
Photo 3. Completed repair - vertical x 2
Figure 1a. Trimmable depth penetration limiter and meniscal depth
probe
Figure 1b. Trimmable depth penetration limiter
5

Photo 4. Holding needle like a dart
Photo 5. Metal slotted cannula
Figure 2. Portal placement
Vertical Incision
Mid-1/3 and Posterior-1/3 Tears
The inferolateral/inferomedial portal
should be 5 mm off the patella
tendon, 1 cm above the joint line.
Anterior-1/3 Tears
The lateral portal should be in front
of the illiotibial band, 1 cm above
the joint line.
The medial portal should be in front
of the medial collateral ligament,
5 mm above the joint line.
The supralateral or supramedial
portal can also be used to access
the anterior horn.
Procedure
First, locate the portals using an 18 gauge spinal
needle to precisely select the insertion direction/
vector. For mid-1/3 and posterior-1/3 tears, make a
vertical portal incision 5 mm off the patella tendon
and 1 cm above the joint line. For anterior-1/3 tears,
position the lateral portal in front of the illiotibial
band, 1 cm above the joint line. The medial portal
should be made in front of the medial collateral
ligament, 5 mm above the joint line. The supralateral
or supramedial portal can be used to access the
anterior horn.
To create the portals, use a knife to excise the tissue
through to the joint and an obturator to dilate the
portal. Use a meniscal depth probe to determine if
an ipsilateral or contralateral portal is best.
Meniscal tear site preparation is essential and
advised. Meniscal rasps and/or arthroscopic
shavers are used to stimulate the tear site and the
peripheral vasculature.
1. Insert the ULTRA FAST-FIX Delivery Needle into
the appropriate arthroscopy portal, holding it like
a dart (Photo 4). Insertion is facilitated through
the use of either the metal slotted cannula
(Photo 5) or the blue split cannula. Place the
ULTRA FAST-FIX device either through the inferior
(tibial) or superior (femoral) surface of the
meniscus for optimal strength.
Note: For the easiest knot sliding and avoidance
of the neurovascular bundles, insert the needle
perpendicular to the tear using a contralateral
approach. Use portals placed adjacent to
the patella tendon (Figure 2) to facilitate this
procedure.
The split sheath cannula obviates the need for a
larger cannula incision and the need to pass the
needle through a diaphragm. In addition, it can
be partially or totally removed by retraction and
peeling.
6

Caution: The opening of the split cannula must
be at 90° to the curved ULTRA FAST-FIX needle
to prevent the needle from slipping out as it is
introduced into the knee (Figure 3). If using the
slotted cannula, make sure the curve of the
needle faces down (Figure 3a).
To minimize needle bending, grasp the cannula
on the shaft and hold it like a dart or pencil when
passing through the fat pad (Photo 4).
Note: The pretied, self-sliding knot, included in
the ULTRA FAST-FIX device, slides from the first
implant (T1) to the second implant (T2). Therefore,
placing T1 further away than T2 will facilitate
sliding of the knot.
Note: Maintaining the needle insertion tip within
the arthroscopic view at all times avoids suture
tangling.
2. For a horizontal repair, place the first implant (T1)
farthest away and advance the needle into the
outer meniscal fragment until the implant pops
through the meniscus.
For a vertical repair, place the superior implant
first and advance the needle into the outer
meniscal fragment (bisecting the fragment) until
the implant pops through the meniscus (Photo 6).
Using the curved ULTRA FAST-FIX device may
facilitate initial penetration.
Using the slotted cannula minimizes needle
skiving when accessing more anterior tears.
Leave the cannula in to help steer the needle tip.
3. Oscillate the needle approximately 5° and pull
the needle out of the meniscus, releasing
T1 behind the meniscus (Figure 4).
To reduce the amount of suture in the field
of view, slowly pull back on the needle after
deploying implant 1. Use a forefinger for control
upon withdrawal. Piercing the meniscus by
2–3 mm prior to advancing T2 can also help with
suture management.
Figure 3. Blue split cannula positioned 90° to the curve of the
delivery needle
Figure 3a. Needle curve facing down
Photo 6. Implant 1 placed superior to tear
Figure 4. Placement of implant 1
7

4. Using the tip (rather than the volar pad) of the
thumb, slide the gold trigger forward to advance
the second implant into the ready position
(Photo 7 and Figure 5).
Note: It is normal to encounter resistance prior
to achieving the ready position. A snap or click
is heard when the trigger is fully advanced,
ensuring that the implant is fully seated at the
end of the needle (Figures 6 and 7).
Photo 7. Implant 2 fully advanced to the ready position
Figure 5. Implant 2 fully advanced to the ready position
Figure 6. Proper positioning of implant 2 Figure 7. Improper positioning of implant 2
8

5. Insert the delivery needle to release implant 2.
≠ For a horizontal repair, insert the needle
between the entry point and the first implant,
approximately 4–5 mm inferior from implant 1
(Figure 8, Photo 8).
≠ For a vertical repair, insert the needle
approximately 4–5 mm inferior from implant 1
(Figure 8, Photo 9).
Figure 8. Implant 2 ready for release
Photo 8. Horizontal mattress suture
Photo 9. Vertical mattress suture
9

Figure 9. Prior to tightening suture construct
6. Remove the delivery needle from the knee,
leaving the free end of the suture. Pull the free
end of the suture to advance the sliding knot
and reduce the meniscal tear (Figure 9, Photos
10 and 11). It is normal to encounter considerable
resistance as the knot is snugged down. It is
important to pull the free end of the suture in a
line directly perpendicular to the tear site.
Avoid suture breakage by wrapping the suture
around several fingers and using the tibia as
a fulcrum to provide a tactile feel. Apply slow,
increasing tension. In most cases, this steady
pulling of the suture will cinch the knot down. As
the knot is tightened, it may strangle the free leg
of suture, creating a loop of suture. If controlled
tightening does not eliminate the loop, place a
probe under the tight leg of suture and use it as
a pulley.
7. To further snug down the suture construct,
thread the free end of the suture through the
ULTRA FAST-FIX Knot Pusher/Suture Cutter. Both
curved and straight knot pushers/suture cutters
are available. This threading can be facilitated
with the use of the suture funnel.
Photo 10. Hand-tightened suture construct - vertical mattress
Photo 11. Hand-tightened suture construct - horizontal mattress
10

8. While holding the suture taut, gently slide the
knot pusher/suture cutter to the meniscus to
achieve the desired tension (Figure 10). The knot
pusher should engage the suture in a direct line
and perpendicular to the repair. A manual suture
“pull”/“push” maneuver is suggested.
9. Rest the tip against the knot to allow for a
2–3 mm suture tail. Cut the suture by sliding
the gold trigger forward (Photos 12 and 13,
Figure 11). Alternatively, trim the suture with
arthroscopic scissors.
To reduce puckering that may result from
the femoral surface repair, the implants can
subsequently be placed on the tibial side of the
meniscus to help pull down the meniscal flap.
The reverse curve ULTRA FAST-FIX device is
recommended for tibial side tears.
Postoperative Care
Reestablish full extension and quadriceps activation
early, along with joint kinematics and proprioception
involving the entire kinetic chain progression to full
weight bearing; limit flexion to 90° for three weeks
and to torsion for six weeks. Running is indicated at
8–12 weeks. Cutting activities are indicated at 10–12
weeks. Return to full activity is indicated at 3–6
months. Individualization is based on the stability of
the tear, repair construct security, and associated
pathology.
Figure 10. Suture construct tensioning
Figure 11. Suture cutting
Photo 12. Suture cutting - horizontal mattress
Photo 13. Suture cutting - vertical mattress
11

Additional Instruction
Prior to performing this technique, consult the
Instruction for Use documentation provided with
individual components – including indications,
contraindications, warnings, cautions, and
instructions.
References
1. Caborn, Borden, Nyland, Pienkowski:
Biomechanical Comparison of the FAST-FIX
Meniscal Repair Suture System with Vertical
Mattress Sutures and Meniscus Arrows.
The American Journal of Sports Medicine,
Vol 31, No. 3, 2003.
2. Coen, Caborn, Urban, et al: Arthroscopy 1998.
Courtesy of Smith & Nephew, Inc.,
Endoscopy Division
Caution: U.S. Federal law restricts this device to sale
by or on the order of a physician.
Trademarks of Smith & Nephew, registered U.S. Patent & Trademark
Office.
Pearls
≠ Prepare site and assess geometry of reduction.
≠ Reduce tear center-to-center to avoid “dog ears”/
gapping/ruffles.
≠ Approach tear from contralateral portal/view from
ipsilateral portal.
≠ Use curve of needle to increase safety zone of
vector and improve insertion positioning.
≠ Hold delivery needle like a dart to stabilize.
≠ Insert curved delivery needle within split cannula
with convexity up.
≠ Ease insertion using metal slotted cannula.
≠ Vertical mattress suture: T1 goes posterior and
superior; T2 goes anterior and inferior.
≠ Insert T2 (implant 2) 4 mm to 5 mm from T1
(implant 1).
≠ Advance gold slide trigger and implant 2
completely to tip until a click is heard (requires
force). Use the tip of the thumb on slide trigger
rather than volar pad of thumb.
≠ If implant 1 does not deploy, it is most likely NOT
inserted through the entire meniscal tissue:
advance deeper.
≠ If implant 2 does not deploy, it is most likely NOT
advanced to the deployment position at the tip of
the delivery needle.
≠ Thread suture onto knot pusher/suture cutter
with suture funnel.
≠ If the knot does not cinch smoothly, it usually
requires a more forceful steady pull which is
facilitated by wrapping the suture around several
fingers like a pulley and applying traction.
≠ Cinch knot to obtain compression of the suture
across the tear but avoid over-cinching or
puckering the tissue.
≠ Alternate divergent femoral side and tibial
(tensile) side suture placement.
≠ Consider reverse curved devices for tibial side
fixation.
Endoscopy
Smith & Nephew, Inc.
Andover, MA 01810
USA
www.smith-nephew.com
+1 978 749 1000
+1 978 749 1108 Fax
+1 800 343 5717 U.S. Customer Service
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All rights reserved.
02/2008 1061031 Rev. C